Cycle 1
Health 2025-03-06 · Fire 2025-03-06
11 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Lewisville, TX
Lake Village Nursing And Rehabilitation Center
2-star overall rating with 3-star inspections with $24,585 in total fines with 11 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
169 Lake Park Rd, Lewisville, TX
(972) 436-7571
Overall
2 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
112
Certified beds
Average residents
75
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1996-01-04
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.40
Registered nurse staffing
LPN hours / resident day
0.86
Licensed practical nurse staffing
Aide hours / resident day
1.79
Nurse aide staffing
Weekend hours
2.48
Weekend nurse staffing
RN turnover
0%
Annual RN turnover
Total nurse turnover
63%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.4 |
2.1
0.3 pts worse
|
1.9
0.5 pts worse
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
2.1
0.6 pts better
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
97.1%
2.5 pts better
|
93.4%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.9%
2.1 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.8% |
3.3%
2.5 pts better
|
3.3%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 0.8% |
2.7%
1.9 pts better
|
11.4%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 1.4% |
3.3%
1.9 pts better
|
5.4%
4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.1% |
18.9%
0.8 pts better
|
19.6%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 12.4% |
10.8%
1.6 pts worse
|
16.7%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 24.4% |
15.4%
9 pts worse
|
16.3%
8.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 27.7% |
16.1%
11.6 pts worse
|
14.9%
12.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.5%
0.5 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.1% |
15.0%
3.1 pts worse
|
19.8%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 2.0% |
4.2%
2.2 pts better
|
5.1%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.8% |
89.7%
9.1 pts better
|
81.7%
17.1 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.8% |
12.0%
7.2 pts better
|
12.0%
7.2 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.5%
0.9 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.1% |
88.0%
7.1 pts better
|
79.7%
15.4 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.3% |
25.9%
3.6 pts better
|
23.9%
1.6 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-26 · Fire 2024-01-26
14 health deficiencies
Top issue: Resident Rights (4 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2022-11-30 · Fire 2022-11-30
1 health deficiencies
Top issue: Infection Control (1 deficiency)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-06
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-03-28
F · Potential for more than minimal harm
2025-03-06
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-03-31
F · Potential for more than minimal harm
2024-01-26
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-02-13
F · Potential for more than minimal harm
2024-01-26
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-03-07
F · Potential for more than minimal harm
2024-01-26
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2024-02-28
D · Potential for more than minimal harm
2022-11-30
K344 · Smoke Deficiencies
Fire Safety
Have an alternate power supply for its alarm system.
Corrected 2022-12-31
C · Minimal harm
2022-11-30
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-12-08
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-28
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Not marked corrected
D · Potential for more than minimal harm
2025-11-28
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Not marked corrected
D · Potential for more than minimal harm
2025-09-16
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-10-15
D · Potential for more than minimal harm
2025-09-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-10-15
E · Potential for more than minimal harm
2025-03-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-04
D · Potential for more than minimal harm
2025-03-06
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-04-04
D · Potential for more than minimal harm
2025-03-06
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-04-04
D · Potential for more than minimal harm
2025-03-06
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-04-04
D · Potential for more than minimal harm
2025-03-06
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-04-04
D · Potential for more than minimal harm
2025-03-06
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-04-04
D · Potential for more than minimal harm
2025-03-06
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-04-04
E · Potential for more than minimal harm
2024-12-04
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-12-31
E · Potential for more than minimal harm
2024-12-04
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-12-31
K · Immediate jeopardy
2024-01-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-28
F · Potential for more than minimal harm
2024-01-26
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2024-02-28
E · Potential for more than minimal harm
2024-01-26
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-02-28
E · Potential for more than minimal harm
2024-01-26
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-02-28
E · Potential for more than minimal harm
2024-01-26
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-02-28
E · Potential for more than minimal harm
2024-01-26
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-02-28
D · Potential for more than minimal harm
2024-01-26
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-02-28
D · Potential for more than minimal harm
2024-01-26
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2024-02-28
D · Potential for more than minimal harm
2024-01-26
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-02-28
D · Potential for more than minimal harm
2024-01-26
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-02-28
D · Potential for more than minimal harm
2024-01-26
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-02-28
D · Potential for more than minimal harm
2024-01-26
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-02-28
D · Potential for more than minimal harm
2022-11-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-12-28
Penalties and ownership
What sits behind the stars
$24,585
2024-01-26
Fine
Fine · fine $24,585
Fine
$0
2024-01-26
Payment Denial
Payment Denial · denial start 2024-02-28 · 8 days
8 day denial
Ownership
Eastland Memorial Hospital District
5% Or Greater Direct Ownership Interest · Organization
Burnam, Soon
Corporate Officer · Individual
Grand Villa Phx, Inc.
Operational/Managerial Control · Organization
Hernandez, Miguel
Operational/Managerial Control · Individual
Keetch, Chad
Corporate Officer · Individual
Mall, Allen
Operational/Managerial Control · Individual
Taylor, Stephen
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Rambling Oaks Courtyard Extensive Care Community
Highland Village, TX
3-star overall rating with 3-star inspections with $21,640 in total fines with 12 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Hollymead
Flower Mound, TX
3-star overall rating with 3-star inspections with $9,110 in total fines with 10 recent health deficiencies
#3
Cross Timbers Rehabilitation and Healthcare Center
Flower Mound, TX
3-star overall rating with 3-star inspections with $8,281 in total fines with 11 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
Jump out